Medical Questionnaire – Psychological Health Last Name(Required) First Name(Required) Date of Birth(Required) DD dash MM dash YYYY Please read each question and select the answer that applies most to you over the past two weeks. There are no right or wrong answers. Don’t spend too much time on each question and answer spontaneously.Feeling sad, depressed, or hopeless Never Several days More than half of the days Almost every day Difficulty falling asleep or staying asleep, or sleeping too much Never Several days More than half of the days Almost every day Little interest or pleasure in doing things Never Several days More than half of the days Almost every day Feeling tired or having low energy Never Several days More than half of the days Almost every day Poor appetite or overeating Never Several days More than half of the days Almost every day Poor self-perception, or you think you're a loser or that you haven't met your own or your family's expectations. Never Several days More than half of the days Almost every day Difficulty concentrating on things such as reading the newspaper or watching television. Never Several days More than half of the days Almost every day You move or speak so slowly that other people may have noticed. Or on the contrary, you are so restless that you move a lot more than usual. Never Several days More than half of the days Almost every day You thought you'd be better off dead or thought about hurting yourself in some way Never Several days More than half of the days Almost every day Feeling nervous, anxious, or tense Never Several days More than half of the days Almost every day Unable to stop worrying or control your worries Never Several days More than half of the days Almost every day Excessive worries about everything and nothing Never Several days More than half of the days Almost every day Difficulty relaxing Never Several days More than half of the days de la moitié des jours Almost every day Bustle so much that it's hard to sit still Never Several days More than half of the days Almost every day Becoming easily upset or irritable Never Several days More than half of the days Almost every day Being afraid that something terrible could happen Never Several days More than half of the days Almost every day CAPTCHA
